Due to the COVID-19 pandemic, the number of home births rose by nearly 20%, from about 38,000 homebirths in 2019 to more than 45,000 in 2020! (Source) However, the rates of homebirths and midwifery care in the United States have slowly and steadily risen since before the pandemic.
Why Do More Parents Want Midwifery Care?
It’s not just that more people want to have a midwife at their birth because it’s not the American norm. More parents are hiring midwives for their maternity care because they want the midwifery model of care.
“The midwifery model of care emphasizes normalcy and wellness. It empowers women and gives them greater ownership of their health, their pregnancy, and the outcomes of that pregnancy based on choices that they’re able to make… Unfortunately, the medical model of prenatal care can take some of that ownership away, in a way that can ultimately be detrimental for some people,” explains Dr. Timothy J. Fisher, OB-GYN residency program director at Dartmouth Hitchcock Medical Center and assistant professor of obstetrics at the Geisel School of Medicine at Dartmouth University.
In the United States, many parents don’t consider other options besides an OB-GYN for their care, however, this is changing as more people are being exposed to the other options.
Saraswathi Vedam, FACNM, a midwife for 35 years, midwifery researcher, and professor at the University of British Columbia, says, “We have a generation of consumers now who are socialized that they should have a voice in making decisions about their own healthcare. In previous generations, it was more normative to (give) control about healthcare decisions to the provider.”
More reasons parents are choosing midwifery care may include:
- Previous traumatic or disappointing birth experiences on the labor and delivery floors of hospitals with OB-GYNs
- A response to the rising cesareans in the U.S.
- Developed ountries with more midwives have lower rates of maternal and infant mortality
- Nearly half of the counties in the U.S. do not have a single OB-GYN
- The number of hospitals providing obstetric services has fallen 16% since 2004
- Wanting your prenatal care provider present at your birth with you
- Desiring a hands-off birth experience. When a woman is low-risk, is in a safe and calm birth space, and believes in her baby and body, she may want to have a hands-off birth expereince where she is remaining in the moment. This may help her remember that she is in control and has a midwife for help if that’s needed!
Evidence-Based Benefits of Midwifery Care:
With midwifery care, babies:
- Have significantly lower rates of preterm birth and low-birthweight infants (Source)
- Less likely to suffer from fetal distress (abnormal fetal heart tones) and birth trauma during labor and birth.
- Less likely to require newborn resuscitation or special care in the neonatal intensive care unit (NICU).
- More likely to remain with their mothers throughout the hospital stay and be exclusively breastfed at two and four months.
Women who choose midwifery care have:
- Longer prenatal appointment times (mostly, if you’re outside of the hospital system)
- Lower costs for both clients and insurers (Source)
- Higher rates of vaginal delivery (Source)
- Lower rates of Cesareans (Source)
- Reduced rates of labor induction & augmentation (Source)
- Better maternal and infant health (Source)
- Lower maternal and fetal mortality. This study found the states in the U.S. with the most integrated of all kinds of midwives resulted in the lowest maternal and fetal mortality.
- Increased satisfaction with care and experience (Source)
- Improved psycho-social outcomes
- Lower rates of miscarriage (Source)
- Fewer hospital admissions during the antepartum period (pregnancy).
- A lower incidence of hypertension during pregnancy and labor.
- Less need for pain medication in labor, including epidural analgesia. (Source)
- A lower incidence of shoulder dystocia, in comparison to similar women cared for by physicians.
- A lower rate of instrumental deliveries (use of forceps or vacuum extractors). (Source)
- A lower incidence of retained placenta and fewer or equivalent postpartum hemorrhages.
- Fewer perineal injuries and fewer 3rd and 4th degree lacerations.
- Safer birth experiences for some. Midwifery care can be safer than care from an OB-GYN for low-risk women.
If you’re interested in a low-intervention childbirth experience, check out these Evidence-Based Ways to Decrease Your Risk of a Cesarean Birth (Coming soon!)
How is Midwifery Care Safer for Low-Risk Pregnant Women?
In the United States, 92-94% of pregnancies are low-risk. Some say that midwifery care is safer than physician care for these low-risk mothers and babies. (Source) But how could this be?
A Cochrane Review looked at 15 studies that involved a total of 17,674 mothers and babies to compare midwife-led models of care to other models of care for women during pregnancy, birth, and early parenting. (This trial did not include models of care that included home birth).
The main benefits of midwives shown in this large systematic review included that women:
- Were less likely to have an epidural
- Had fewer episiotomies
- Had fewer instrumental births such as, forceps or a vacuum
- Were less likely to experience preterm birth
- Had increased chances for a spontaneous vaginal birth
- Were at a lower risk of losing their babies
Another study compared midwifery and obstetrics in low-risk hospital births and found the mothers with midwifery care had:
- 30% lower risk of cesarean birth in first time moms
- 40% lower risk of cesarean in moms who have given birth before
The more women who have unnecessary cesareans lead to more maternal deaths for those who go on to have more pregnancies with more cesareans. Therefore, this is why it’s crucial for cesareans to be avoided unless they’re necessary. Additionally, more episiotomies lead to longer recovery times for mothers.
Furthermore, this especially compelling study from Canada showed when the same midwives provided care for both low-risk women planning home births and women planning hospital births, the homebirths had fewer interventions. This study shows that if you’re low risk and desiring an unmedicated, zero-intervention birth that your chances could be higher with a homebirth.
The Different Kinds of Midwives:
Midwives in the U.S. vary in what education and training they have received. Although this needs to change, let’s talk about each type of midwife!
Certified Nurse-Midwives (CNMs)
CNMs are nurses with a graduate degree in nurse-midwifery.
Before starting their master’s or doctorate in nurse-midwifery, they first must obtain a bachelor of science in nursing. Plus, most (if not all) work for some time on the labor and delivery unit in the hospital before becoming student nurse-midwives.
Nurse-midwives are advanced practice nurses and/or nurse practitioners who are legal to practice in all U.S. jurisdictions and can prescribe medications and contraception.
They can work in hospitals, clinics, birth centers and can provide home births.
Certified Midwives (CMs)
CMs have the same scope of practice as CNMs, but they are only legal to practice in 3 states in the U.S.: New York, Rhode Island, and Maine.
Certified Midwives received a bachelor’s degree in a health-related field other than nursing, then graduated from a master’s (or doctorate) level midwifery program. They have similar training to CNMs, conform to the same standards as CNMs, but do not have a nursing background.
While they’re technically direct-entry midwives, they are considered equal to CNMs (in the states that they are legal) since their scope is the same.
Certified Professional Midwives (CPMs)
Next, there are CPMs, which are legally recognized in 35 states in the U.S. Their education and training are focused on providing care in homes and freestanding birth centers.
The first option to becoming a CPM is through the PEP process through NARM (The North American Registry of Midwives) where a student midwife has at least one apprentice and fulfills a number of births as an observer, assistant, and then the primary care provider. This process must take at least 2 years to complete and typically takes students more like 4 or 5 years.
The second way to become a CPM is by earning a Bachelor’s of Science in Midwifery which includes working with a preceptor for extremely similar clinical experience requirements as the first option as well as fulfilling 120 credits for the degree. This option typically takes students 4-7 years to complete. You can find the exact classes required in this program plan from the Midwives College of Utah here.
Unlike certified nurse-midwives, CPMs cannot prescribe medications or contraceptives, but they can obtain and administer all the medications needed in the select states they are legally recognized. Certified Professional Midwives are specialized in normal, healthy pregnancy and birth, typically helpful with preventative health care, and are trained for emergencies. They also have full practice authority without physician supervision (unlike many nurse-midwives).
If you’re interested in comparing midwives to OB-GYNs check out, How to Choose Between a Midwife or an OB-GYN?
Traditional/Unlicensed Midwives:
These midwives choose not to become licensed sometimes for cultural or religious reasons. Their training and background can vary greatly. Often, traditional/unlicensed midwives serve specific communities, such as indigenous communities or religious populations.
Do Certified Nurse Midwives Practice the Midwifery Model of Care?
The shortest answer I have is that it depends. Nurse-Midwives in the U.S. are the first nurses who have been trained in the medical model of care. Then, throughout nurse-midwifery school, they’re still being trained only in the hospital following protocols that still aren’t evidence-based. Furthermore, if a nurse-midwife or any provider wants to give their client evidence-based care that goes against the culture of that hospital, then the provider themselves can get in trouble, big trouble.
There are also some nurse-midwives in the birth work community that we refer to as “med-wives” because instead of ever wanting to become a nurse-midwife to be a midwife it may just have been for the increase in pay.
If you’re looking for a nurse-midwife to have low or zero-intervention labor and childbirth I recommend figuring out the hospital’s labor and delivery protocols and seeing if they have a birth center that’s a part of the hospital! A birth center like this can be perfect to be with nurses and midwives who want to work with low-intervention births. Plus, you will be away from the OBs mostly and the women laboring with epidurals if that makes you feel more comfortable!
Sources
Midwife‐led continuity models versus other models of care for childbearing women
Mapping integration of midwives across the United States: Impact on access, equity, and outcomes
Midwife‐led continuity models versus other models of care for childbearing women
Evaluation of satisfaction with midwifery care
Reducing neonatal mortality rate with nurse-midwives
DISCLAIMER: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding you or your baby’s health. Please read my Medical Disclaimer for more info
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